嚴(yán)重?zé)齻笊铎o脈導(dǎo)管相關(guān)感染并發(fā)顱內(nèi)多發(fā)性膿腫一例(編輯修改稿)
2024-10-04 12:50 本頁面
【文章內(nèi)容簡(jiǎn)介】 and front lobe. Pressurized water sequence image showed high signal, enhanced scan showed evident ring enhancement or inplete enhancement, and partial cerebral sulcus and cerebral fissure got narrowed. The biggest focus lied in right temporal lobe and the size was about 3cm, and there were still seperated tiny specks of focus in both sides of brain and left showed there was multiple infection focus in both sides of brain and cerebella and some abscess had formed. Combined with clinic data it was diagnosed to be cerebral multiple MRSA infection after burnt and some abscess had was transferred to neurology department, vanycin continued to be used and bined with fosfomycin sodium to prevent infection with treatment of mannitol dehydrating to reduce cerebral pressure. One week later patient died of abscess rupture.討論：燒傷后感染等并發(fā)癥至今仍然是燒傷治療中棘手的問題之一，特別是多重耐藥細(xì)菌的感染并發(fā)癥。燒傷后并發(fā)顱內(nèi)感染雖然較少見，但仍有病例報(bào)道[1]，多見于兒童,成人也可發(fā)生。感染多為血源播散性,與嚴(yán)重?zé)齻髾C(jī)體免疫功能低下易發(fā)生侵襲性感染有關(guān)，也有醫(yī)源性因素如深靜脈導(dǎo)管的相關(guān)性感染所致[2]。感染的病源菌多與病區(qū)優(yōu)勢(shì)致病菌一致，如銅綠假單胞菌、金黃色葡萄球菌等。燒傷后由耐甲氧西林的金黃色葡萄球菌（MRSA）所致的顱內(nèi)感染較為少見，1992年Suzuki 報(bào)道一例[3]。由于燒傷后顱內(nèi)感染早期多與侵襲性感染癥狀相似，易漏診，腦膜炎癥后，對(duì)MRSA敏感的抗菌素如萬古霉素等難以透過血腦屏障，給治療帶來很大困難。本例燒傷面積為35%，燒傷創(chuàng)面主要分布在頭面部和四肢暴露部位，因常用的外周靜穿刺部位均被燒傷而選擇了深靜脈置管。在傷后2周創(chuàng)面基本愈合時(shí)，突發(fā)高熱、白細(xì)胞增高等全身感染表現(xiàn)，創(chuàng)面分泌物、深靜脈導(dǎo)管及血培養(yǎng)均培養(yǎng)出MRSA，結(jié)合病程、臨床表現(xiàn)和各項(xiàng)檢查，可診斷顱內(nèi)多發(fā)性膿腫源于右股靜脈導(dǎo)管的MRSA相關(guān)感染。盡管選用了敏感抗菌素，但萬古霉素難以透過血腦屏障，局部組織難以達(dá)到有效的殺菌濃度，最終治療失敗。燒傷后留置深靜脈導(dǎo)管，一旦發(fā)生導(dǎo)管感染和化膿性栓塞性靜脈炎，會(huì)給后續(xù)的病灶清除術(shù)帶來困難，因此，有作者認(rèn)為，留置導(dǎo)管時(shí)應(yīng)盡量避免使用深靜脈[4]。但在臨床實(shí)際工作中，對(duì)大面積深度燒傷病例，留置深靜脈導(dǎo)管有時(shí)在所難免，但要盡可能選擇血流速度快，不易形成血栓的部位，如頸內(nèi)靜脈、鎖骨下靜脈等。導(dǎo)管留置超過7日以上,特別是股靜脈部位,導(dǎo)管相關(guān)性感染的機(jī)率會(huì)明顯增加[5] 。因此,達(dá)到治療目的后,應(yīng)盡早拔除,需要較長(zhǎng)時(shí)間使用的,應(yīng)定期重新穿刺,更換導(dǎo)管。本病例入院時(shí)因四肢常用的外周靜脈穿刺部位皮膚被燒傷,而選用了右股靜脈穿刺置管,但未能及時(shí)更換,且留置時(shí)間過長(zhǎng),增加了發(fā)生導(dǎo)管相關(guān)感染的機(jī)會(huì),應(yīng)特別引起重視。此外,留置深靜脈導(dǎo)管后,還應(yīng)加強(qiáng)插管部位皮膚的護(hù)理，保持局部干燥、清潔，導(dǎo)管內(nèi)使用抗凝劑，采用抗生素鎖技術(shù)等也能有效地減少深靜脈導(dǎo)管相關(guān)性感染的發(fā)生。 譯文：Discussion:Complications such as infections after burnt are still one of the thorny problems in burn treatment to date, especially the plication caused by multiple drugresistant cerebral infection superinduced after burnt is seldom, there are still medical cases reported. It is more mon in children, also possible in the adult. Most infections are blood disseminated which are related to lower immune function after burnt which bees susceptible to infection. There are also iatrogenic factors such as deep vein catheters related infec
環(huán)評(píng)公示相關(guān)推薦
鄂ICP備17016276號(hào)-1